Differential Diagnosis for Chronic Fatigue Syndrome

to the editor: I have just read the recent article on chronic fatigue syndrome (CFS).1 While the authors present an excellent framework for the evaluation and management of patients with chronic fatigue, they have overlooked a differential diagnosis. Celiac disease, also known as gluten-sensitive enteropathy (GSE), may present as CFS2–5 and is highly treatable.

A study2 reported that 2 percent of 100 patients who met diagnostic criteria for CFS actually had occult GSE. Neither patient reported symptoms typical of celiac disease and both had normal hematologic and serum protein analysis. Both patients were under treatment for hypothyroidism and were euthyroid. One article3 presents a case report of a patient with occult celiac disease who fit the criteria for CFS. This author suggested that autoantibodies against endomysium (transglutaminase) and gliadin be routinely evaluated in patients presenting with chronic fatigue. Another study4 found a high prevalence of GSE in patients with vague chronic symptoms such as fatigue and lassitude.

A review article5 on celiac disease suggests that patients with fatigue should be screened for GSE. Certainly patients with iron deficiency and symptoms such as diarrhea should be evaluated for GSE. I propose that GSE be considered in the evaluation of patients who meet the criteria for CFS.

in reply: Thank you to Dr. Nelsen for bringing up this item. This would increase our differential diagnosis that must be included to successfully exclude diseases that may mimic chronic fatigue syndrome.

Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.